Provider Demographics
NPI:1093911836
Name:CORSON, EILEEN ELIZABETH (PTA)
Entity Type:Individual
Prefix:MRS
First Name:EILEEN
Middle Name:ELIZABETH
Last Name:CORSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SUNSET
Mailing Address - State:TX
Mailing Address - Zip Code:76270-7160
Mailing Address - Country:US
Mailing Address - Phone:940-366-2133
Mailing Address - Fax:940-567-3924
Practice Address - Street 1:211 E JASPER ST
Practice Address - Street 2:
Practice Address - City:JACKSBORO
Practice Address - State:TX
Practice Address - Zip Code:76458-1848
Practice Address - Country:US
Practice Address - Phone:940-567-3924
Practice Address - Fax:940-567-3924
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2034924225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant